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Koceva A, Kravos Tramšek NA. From Sweet to Sour: SGLT-2-Inhibitor-Induced Euglycemic Diabetic Ketoacidosis. J Pers Med 2024; 14:665. [PMID: 39063919 PMCID: PMC11277626 DOI: 10.3390/jpm14070665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT-2) inhibitors are highly selective, effective, and generally well-tolerated antihyperglycemic agents targeting the SGLT-2 transmembrane protein. Despite being primarily registered for diabetes treatment, due to their cardiorenal protective properties, SGLT-2 inhibitors caused a paradigm shift in the treatment of other diseases on the cardiorenal spectrum, becoming a fundamental part of heart failure and chronic kidney disease management. With their rapidly increasing use, there are also increased reports of a rare, often under-recognised and potentially deadly side effect, SGLT-2-inhibitor-induced euglycemic diabetic ketoacidosis (EDKA). The primary pathophysiological process behind its multifactorial aetiology comprises glucosuria and osmotic diuresis, which produce a significant carbohydrate deficit, leading to an increase in the glucagon-insulin ratio, thus resulting in accelerated ketogenesis. Although EDKA has a similar clinical presentation as diabetic ketoacidosis (DKA), the absence of the high glucose levels typically expected for DKA and the presence of urine ketone reabsorption contribute to a significant delay in its recognition and timely diagnosis. Given the broad use of SGLT-2 inhibitors, increased awareness, early recognition, and prompt identification of precipitating factors are essential. In this narrative review, we comprehensively explore the pathophysiological mechanisms of SGLT-2-inhibitor-induced EDKA, analyse its clinical manifestation, and identify the most common triggers for its development. We also discuss EDKA management and preventive strategies.
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Affiliation(s)
- Andrijana Koceva
- Department of Endocrinology and Diabetology, University Medical Center Maribor, Ljubljanska Ulica 5, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
| | - Nika Aleksandra Kravos Tramšek
- Department of Endocrinology and Diabetology, University Medical Center Maribor, Ljubljanska Ulica 5, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Taborska ulica 8, 2000 Maribor, Slovenia
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Shou Y, Li X, Fang Q, Xie A, Zhang Y, Fu X, Wang M, Gong W, Zhang X, Yang D. Progress in the treatment of diabetic cardiomyopathy, a systematic review. Pharmacol Res Perspect 2024; 12:e1177. [PMID: 38407563 PMCID: PMC10895687 DOI: 10.1002/prp2.1177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 12/29/2023] [Accepted: 01/19/2024] [Indexed: 02/27/2024] Open
Abstract
Diabetic cardiomyopathy (DCM) is a condition characterized by myocardial dysfunction that occurs in individuals with diabetes, in the absence of coronary artery disease, valve disease, and other conventional cardiovascular risk factors such as hypertension and dyslipidemia. It is considered a significant and consequential complication of diabetes in the field of cardiovascular medicine. The primary pathological manifestations include myocardial hypertrophy, myocardial fibrosis, and impaired ventricular function, which can lead to widespread myocardial necrosis. Ultimately, this can progress to the development of heart failure, arrhythmias, and cardiogenic shock, with severe cases even resulting in sudden cardiac death. Despite several decades of both fundamental and clinical research conducted globally, there are currently no specific targeted therapies available for DCM in clinical practice, and the incidence and mortality rates of heart failure remain persistently high. Thus, this article provides an overview of the current treatment modalities and novel techniques pertaining to DCM, aiming to offer valuable insights and support to researchers dedicated to investigating this complex condition.
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Affiliation(s)
- Yiyi Shou
- Department of Clinical MedicineAffiliated Hospital of Hangzhou Normal University, Hangzhou Normal UniversityHangzhouChina
| | - Xingyu Li
- Department of Clinical MedicineAffiliated Hospital of Hangzhou Normal University, Hangzhou Normal UniversityHangzhouChina
| | - Quan Fang
- Department of Clinical MedicineAffiliated Hospital of Hangzhou Normal University, Hangzhou Normal UniversityHangzhouChina
| | - Aqiong Xie
- Department of Clinical MedicineAffiliated Hospital of Hangzhou Normal University, Hangzhou Normal UniversityHangzhouChina
| | - Yinghong Zhang
- Department of ImmunologyAffiliated Hospital of Hangzhou Normal UniversityHangzhouChina
| | - Xinyan Fu
- Department of CardiologyAffiliated Hospital of Hangzhou Normal UniversityHangzhouChina
| | - Mingwei Wang
- Department of CardiologyAffiliated Hospital of Hangzhou Normal UniversityHangzhouChina
| | - Wenyan Gong
- Department of Clinical MedicineAffiliated Hospital of Hangzhou Normal University, Hangzhou Normal UniversityHangzhouChina
- Department of CardiologyAffiliated Hospital of Hangzhou Normal UniversityHangzhouChina
| | - Xingwei Zhang
- Department of Clinical MedicineAffiliated Hospital of Hangzhou Normal University, Hangzhou Normal UniversityHangzhouChina
- Department of CardiologyAffiliated Hospital of Hangzhou Normal UniversityHangzhouChina
| | - Dong Yang
- Department of Clinical MedicineAffiliated Hospital of Hangzhou Normal University, Hangzhou Normal UniversityHangzhouChina
- Department of CardiologyAffiliated Hospital of Hangzhou Normal UniversityHangzhouChina
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Kamath SD, Kumar U, Shrivastava V. Sodium-Glucose Cotransporter 2 Inhibitor-Induced Euglycemic Diabetic Ketoacidosis: The Other Side of the Coin! Cureus 2024; 16:e58341. [PMID: 38756291 PMCID: PMC11095996 DOI: 10.7759/cureus.58341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
Euglycemic diabetic ketoacidosis (EDKA) though rare is a life-threatening complication of sodium-glucose cotransporter 2 (SGLT2) inhibitors. With their increasing use in the management of type 2 diabetes mellitus (T2DM) due to long-term beneficial effects, the incidence of this complication is on the rise. We report a case of a 58-year-old lady with a history of T2DM on multiple anti-diabetes medications including dapagliflozin for one year, who during intercurrent illness developed EDKA. Her blood sugar on admission was 203 mg/dL, and arterial blood gas showed high anion-gap metabolic acidosis (HAGMA) with ketonuria and ketonemia (blood beta-hydroxybutyric (BOHB) acid level: 5.4 mmol/L). Low carbohydrate intake, dehydration resulting from repeated vomiting, and skipping the previous two days' dose of insulin could have precipitated this condition. She was treated with intravenous fluids, insulin, 5% dextrose infusion, and potassium supplements with complete resolution of acidosis after about 90 hours. This case signifies the importance of awareness of the link between the use of SGLT2 inhibitors and EDKA and early recognition of this complication to reduce morbidity and mortality. Furthermore, it also emphasizes the need for clinicians to educate their patients taking these drugs to stop them during the intercurrent illness to prevent them from developing EDKA.
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Affiliation(s)
| | - Umesh Kumar
- General Medicine, Tata Main Hospital, Jamshedpur, IND
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O'Brolchain A, Maletsky J, Mian I, Edwards S. Does Treatment with Sodium-Glucose Cotransporter-2 Inhibitors Affect Adherence to International Society Criteria for Diabetic Ketoacidosis in Adult Patients with Type 2 Diabetes? A Retrospective Cohort Analysis. J Diabetes Res 2024; 2024:1849522. [PMID: 38516324 PMCID: PMC10957251 DOI: 10.1155/2024/1849522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 03/23/2024] Open
Abstract
Design Retrospective observational study. Setting. Inpatients at two teaching hospitals in Queensland, Australia. Primary Outcome Measure(s). The number of patients meeting the Joint British Diabetes Society (JBDS) and American Association of Clinical Endocrinology/American College of Endocrinology (AACE/ACE) diagnostic criteria for DKA. Patients were divided into two groups by treatment with SGLT2i at the time of diagnosis. Participants. Adult patients (>18 years old) with type 2 diabetes diagnosed with DKA from April 2015 to January 2022. Patients without type 2 diabetes were excluded. Results One hundred and sixty-five patients were included in this study-comprising 94 patients in the SGLT2i cohort and 70 in the non-SGLT2i cohort. A significantly smaller proportion of patients in the SGLT2i vs. non-SGLT2i cohorts met both JBDS (56% vs. 72%, p = 0.035) and AACE/ACE (63% vs. 82%, p = 0.009) criteria for diagnosis of DKA. Conclusion Patients with type 2 diabetes treated with SGLT2i may be more likely to be diagnosed with DKA despite not meeting the criteria. Despite recent adjustments to account the physiological effects of SGLT2i, significant variation in criteria between major society guidelines presents ongoing challenges to clinicians. The proportion of patients diagnosed using both JDBS and AACE/ACE were comparable, suggesting a reasonable degree of agreement.
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Affiliation(s)
- Aongus O'Brolchain
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
- Griffith University, Queensland, Australia
| | - Joshua Maletsky
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Ibrahim Mian
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Serena Edwards
- Department of Medicine, Gold Coast Health, Gold Coast, Queensland, Australia
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Kashiwagi A, Shoji S, Kosakai Y, Yoshinaga Y, Rokuda M. Healthcare resource utilization and healthcare costs in patients with type 2 diabetes mellitus initiating sodium-glucose cotransporter 2 inhibitors vs dipeptidyl peptidase-4 inhibitors in Japan: A real-world administrative database analysis. J Diabetes Investig 2024; 15:374-387. [PMID: 38112598 PMCID: PMC10906021 DOI: 10.1111/jdi.14123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/07/2023] [Accepted: 11/21/2023] [Indexed: 12/21/2023] Open
Abstract
AIMS/INTRODUCTION Healthcare resource utilization (HCRU) and healthcare costs are important factors to consider when selecting appropriate treatment for type 2 diabetes mellitus. We compared the HCRU and healthcare costs of sodium-glucose cotransporter 2 inhibitors (SGLT2i) vs dipeptidyl peptidase-4 inhibitors (DPP4i) in patients with type 2 diabetes mellitus in Japan. MATERIALS AND METHODS This was a Japanese retrospective cohort study conducted using the JMDC Claims Database (January 1, 2015-December 31, 2021). Patients newly treated with an SGLT2i (31,872 patients) or a DPP4i (73,279 patients) were matched 1:1, using propensity score, after excluding patients without continuous SGLT2i or DPP4i prescriptions after the index date. HCRU and healthcare costs were compared between the treatment groups in the full cohort and subcohorts/subgroups of different baseline characteristics, including body mass index (BMI). RESULTS After matching, patient characteristics were well balanced (17,767 patients each). Patients receiving an SGLT2i vs those receiving a DPP4i had significantly lower numbers of hospitalizations per person per month (PPPM) and outpatient visits PPPM, and had shorter lengths of stay per hospitalization. Healthcare costs, including all-cause overall healthcare costs PPPM and all-cause hospitalization costs PPPM, were generally lower in patients receiving an SGLT2i than those receiving a DPP4i. Similar results were observed among patients with a higher BMI but not among patients with a lower BMI. CONCLUSIONS SGLT2i were associated with lower HCRU and healthcare costs than DPP4i, suggesting economic benefits with SGLT2i vs DPP4i in type 2 diabetes mellitus management.
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Affiliation(s)
- Atsunori Kashiwagi
- Department of Diabetes and EndocrinologyOmi Medical CenterKusatsuShigaJapan
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AlKindi F, Boobes Y, Shalwani F, Ansari J, Almazrouei R. Sodium-Glucose Cotransporter 2 Inhibitor (SGLT2i) Associated Diabetic Ketoacidosis in Oncology Patients: A Case Series and Literature Review. Cureus 2024; 16:e53816. [PMID: 38465036 PMCID: PMC10924182 DOI: 10.7759/cureus.53816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/12/2024] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2i) use is associated with an increased risk of diabetic ketoacidosis (DKA). The clinical data regarding the use of SGLT2i and its potential side effects in oncology patients is limited. We are retrospectively reporting four oncology patients with type 2 diabetes mellitus using SGLT2i who were admitted with DKA. The mean age of the patients was 61.25 years, and male to female ratio was 1:1. The duration of type 2 diabetes ranged from 10 to 20 years (mean 15.75 years) and the types of SGLT2i used were empagliflozin 25 mg and dapagliflozin 10 mg. The types of malignancy in our case series included squamous cell carcinoma of the cheek, ovarian cancer, and two patients had laryngeal carcinoma (squamous cell carcinoma). Diabetic ketoacidosis was diagnosed in three patients following chemotherapy or concurrent chemo-radiotherapy. Poor oral intake and infections were the main risk factors in our patients. Mean blood glucose level, anion gap, and bicarbonate level were 11.7 mmol/l, 32.25, and 5 mmol/l, respectively. The majority had moderate DKA based on pH (mean 7.13). The hospital course was complicated by acute kidney injury (n=4), infections (n=4) (urinary tract infections, and pneumonia), and three patients required critical care. The mean length of hospitalization was 19.2 days and no mortality was reported among our patients. SGLT2i-related DKA is an emerging complication recognized in oncology patients. Some of the risk factors for this complication are starvation, poor oral intake, and infection which are quite prevalent in oncology patients. Temporary holding of SGLT2i medication during this period might have a potential preventive role.
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Affiliation(s)
- Fatima AlKindi
- Department of Internal Medicine, Tawam Hospital, Al Ain, ARE
| | - Yousef Boobes
- Seha Kidney Care, Tawam Hospital, Al Ain, ARE
- Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain, ARE
| | - Fatima Shalwani
- Department of Internal Medicine, Tawam Hospital, Al Ain, ARE
| | - Jawaher Ansari
- Department of Oncology, Tawam Hospital, Al Ain, ARE
- Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain, ARE
| | - Raya Almazrouei
- Division of Endocrinology, Tawam Hospital, Al Ain, ARE
- Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain, ARE
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Jiang Y, Li Z, Yue R, Liu G, Yang M, Long C, Yan D. Evidential support for garlic supplements against diabetic kidney disease: a preclinical meta-analysis and systematic review. Food Funct 2024; 15:12-36. [PMID: 38051214 DOI: 10.1039/d3fo02407e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
Garlic (Allium sativum L.) is a popular spice that is widely used for food and medicinal purposes and has shown potential effects on diabetic kidney disease (DKD). Nevertheless, systematic preclinical studies are still lacking. In this meta-analysis and systematic review, we evaluated the role and potential mechanisms of action of garlic and its derived components in animal models of DKD. We searched eight databases for relevant studies from the establishment of the databases to December 2022 and updated in April 2023 before the completion of this review. A total of 24 trials were included in the meta-analysis. It provided preliminary evidence that supplementing with garlic could improve the indicators of renal function (BUN, Scr, 24 h urine volume, proteinuria, and KI) and metabolic disorders (BG, insulin, and body weight). Meanwhile, the beneficial effects of garlic and its components in DKD could be related to alleviating oxidative stress, suppressing inflammatory reactions, delaying renal fibrosis, and improving glucose metabolism. Furthermore, time-dose interval analysis exhibited relatively greater effectiveness when garlic products were supplied at doses of 500 mg kg-1 with interventions lasting 8-10 weeks, and garlic components were administered at doses of 45-150 mg kg-1 with interventions lasting 4-10 weeks. This meta-analysis and systematic review highlights for the first time the therapeutic potential of garlic supplementation in animal models of DKD and offers a more thorough evaluation of its effects and mechanisms to establish an evidence-based basis for designing future clinical trials.
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Affiliation(s)
- Yayi Jiang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China.
| | - Zihan Li
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China.
| | - Rensong Yue
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China.
| | - Guojie Liu
- School of Chemical Engineering, Sichuan University, Chengdu, China
| | - Maoyi Yang
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China.
| | - Caiyi Long
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China.
| | - Dawei Yan
- Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China.
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Al-Hindi B, Mohammed MA, Mangantig E, Martini ND. Prevalence of sodium-glucose transporter 2 inhibitor-associated diabetic ketoacidosis in real-world data: A systematic review and meta-analysis. J Am Pharm Assoc (2003) 2024; 64:9-26.e6. [PMID: 37844733 DOI: 10.1016/j.japh.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/30/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration (FDA) revised the labels of sodium-glucose transporter 2 (SGLT2) inhibitors in December 2015 to inform users regarding the risk of diabetic ketoacidosis (DKA). As more drugs of this class are approved and their indications are expanded, this serious adverse effect has been increasingly reported. OBJECTIVE This review evaluated observational studies to inform the prevalence of SGLT2-inhibitor-associated DKA compared with other antihyperglycemic agents. METHODS A systematic review was conducted in PubMed and EMBASE until 19 July 2022 (PROSPERO: CRD42022385425). We included published retrospective cohort active comparator/new user (ACNU) and prevalent new user studies assessing SGLT2-inhibitor-associated DKA prevalence in adult patients with type 2 diabetes mellitus (T2DM) against active comparators. We excluded studies which lacked 1:1 propensity score matching. The JBI Checklist for Cohort Studies guided the risk-of-bias assessments. Meta-analysis was conducted based on the inverse variance method in R software. RESULTS Sixteen studies with a sample of 2,956,100 nonunique patients met the inclusion criteria. Most studies were conducted in North America (n = 9) and adopted the ACNU design (n = 15). Meta-analysis of 14 studies identified 33% higher DKA risk associated with SGLT2 inhibitors (HR = 1.33, 95% CI: 1.14-1.55, P < 0.01). Meta-regression analysis identified the study location (P = 0.02), analysis principle (P < 0.001), exclusion of chronic comorbidities (P = 0.007), and canagliflozin (P = 0.04) as significant moderator variables. CONCLUSIONS Despite limitations related to heterogeneity, generalizability, and misclassification, the results of this study show that SGLT2 inhibitors increase the prevalence of DKA among adult T2DM patients in the real world. The findings supplement evidence from randomized controlled trials (RCTs) and call for continued vigilance.
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Raiten JM, Morlok A, D'Ambrosia S, Ruggero MA, Flood J. Perioperative Management of Patients Receiving Sodium-Glucose Cotransporter 2 Inhibitors: Development of a Clinical Guideline at a Large Academic Medical Center. J Cardiothorac Vasc Anesth 2024; 38:57-66. [PMID: 37932195 DOI: 10.1053/j.jvca.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 11/08/2023]
Abstract
The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) is increasing rapidly for patients with diabetes, heart failure, and chronic kidney disease. These medications can cause euglycemic diabetic ketoacidosis in the perioperative period, and the Food and Drug Administration recently updated their recommendations that they be held for at least 3-to-4 days preoperatively. There is a paucity of guidelines for the perioperative management of patients taking SGLT2i who present for emergent surgery or elective surgery having not held the medications per Food and Drug Administration guidelines. At the University of Pennsylvania, a multidisciplinary team from the Departments of Anesthesiology, Endocrinology, and Pharmacy has developed comprehensive guidelines detailing preoperative, intraoperative, and postoperative management for patients using these medications. In this article, the authors present these guidelines and discuss challenges encountered while implementing them at a large academic medical center with satellite hospitals and surgery centers with varying resources and patient populations.
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Affiliation(s)
- Jesse M Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Andrea Morlok
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarah D'Ambrosia
- Center for Evidence Based Practice, University of Pennsylvania, Philadelphia, PA
| | - Michael A Ruggero
- Department of Pharmacy, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Jeremy Flood
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Kawahara J, Kaku B, Yagi K, Kitagawa N, Yokoyama M, Wakabayashi Y, Senda S, Takata H, Hiraiwa Y. Life-threatening coronary vasospasm in patients with type 2 diabetes with SGLT2 inhibitor-induced euglycemic ketoacidosis: a report of two consecutive cases. Diabetol Int 2024; 15:135-140. [PMID: 38264228 PMCID: PMC10800321 DOI: 10.1007/s13340-023-00664-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/19/2023] [Indexed: 01/25/2024]
Abstract
Euglycemic diabetic ketoacidosis (eDKA) has emerged as an adverse event associated with sodium-glucose transporter-2 inhibitors (SGLT2i). We present two consecutive cases of SGLT2i-induced eDKA, both manifested as life-threatening coronary vasospastic angina (VSA). Case 1: A 64-year-old male overweight patient with type 2 diabetes (BMI 28.2 kg/m2), treated with dapagliflozin 5 mg daily for 6 months and a restricted diet for 2 months, experienced loss of consciousness following severe chest pain while driving, resulting in a traffic accident: plasma glucose, 163 mg/dL; urine ketones, (+++); bicarbonate (HCO3-), 13.2 mmol/L; and total ketone body, 1539 µmol/L. Coronary angiography (CAG) performed on day 5 revealed diffusely spastic coronary arteries with 90% stenosis in the right coronary artery, leading to the diagnosis of VSA in the presence of coronary atherosclerosis. Case 2: A 63-year-old male patient with type 2 diabetes (BMI 22.2 kg/m2) experienced severe chest discomfort and faintness following 2 months of chest pain while on dapagliflozin 10 mg daily for 1 year: plasma glucose, 112 mg/dL; urine ketones, (+++); HCO3-, 15.3 mmol/L; and total ketone body, 10,883 µmol/L. CAG performed on day 10 revealed no organic stenosis but diffusely spastic coronary arteries in response to coronary ergonovine infusion, confirming the diagnosis of VSA. SGLT2i has the potential to inhibit acetylcholine and butyrylcholine esterase activities, leading to reduced scavenging of acetylcholine and possible induction of coronary vasospasm. These cases highlight the association between life-threatening VSA and SGLT2i-induced eDKA.
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Affiliation(s)
- Junko Kawahara
- Department of Internal Medicine, Toyama Red Cross Hospital, Toyama, Toyama Japan
| | - Bunji Kaku
- Department of Internal Medicine, Toyama Red Cross Hospital, Toyama, Toyama Japan
| | - Kunimasa Yagi
- Department of Internal Medicine, Kanazawa Medical University Hospital, 1-1 Daigaku, Uchinada, Ishikawa 920-0293 Japan
| | - Naotaka Kitagawa
- Department of Internal Medicine, Toyama Red Cross Hospital, Toyama, Toyama Japan
| | - Maki Yokoyama
- Department of Internal Medicine, Toyama Red Cross Hospital, Toyama, Toyama Japan
| | - Yusuke Wakabayashi
- Department of Internal Medicine, Toyama Red Cross Hospital, Toyama, Toyama Japan
| | - Satoko Senda
- Department of Internal Medicine, Toyama Red Cross Hospital, Toyama, Toyama Japan
| | - Hiroyuki Takata
- Department of Internal Medicine, Toyama Red Cross Hospital, Toyama, Toyama Japan
| | - Yoshio Hiraiwa
- Department of Internal Medicine, Toyama Red Cross Hospital, Toyama, Toyama Japan
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Weinberg Sibony R, Segev O, Dor S, Raz I. Drug Therapies for Diabetes. Int J Mol Sci 2023; 24:17147. [PMID: 38138975 PMCID: PMC10742594 DOI: 10.3390/ijms242417147] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/21/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
The treatment of type 2 diabetes (T2D) necessitates a multifaceted approach that combines behavioral and pharmacological interventions to mitigate complications and sustain a high quality of life. Treatment encompasses the management of glucose levels, weight, cardiovascular risk factors, comorbidities, and associated complications through medication and lifestyle adjustments. Metformin, a standard in diabetes management, continues to serve as the primary, first-line oral treatment across all age groups due to its efficacy, versatility in combination therapy, and cost-effectiveness. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) offer notable benefits for HbA1c and weight reduction, with significant cardiovascular benefits. Sodium-glucose cotransporter inhibitors (SGLT-2i) lower glucose levels independently of insulin while conferring notable benefits for cardiovascular, renal, and heart-failure outcomes. Combined therapies emphasizing early and sustained glycemic control are promising options for diabetes management. As insulin therapy remains pivotal, metformin and non-insulin agents such as GLP-1 RA and SGLT-2i offer compelling options. Notably, exciting novel treatments like the dual GLP-1/ glucose-dependent insulinotropic polypeptide (GIP) agonist show promise for substantially reducing glycated hemoglobin and body weight. This comprehensive review highlights the evolving landscape of pharmacotherapy in diabetes, the drugs currently available for treating diabetes, their effectiveness and efficacy, the impact on target organs, and side effects. This work also provides insights that can support the customization of treatment strategies.
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Affiliation(s)
- Roni Weinberg Sibony
- Faculty of Medicine, Ben-Gurion University, Beer Sheva 8443944, Israel; (R.W.S.); (S.D.)
| | - Omri Segev
- Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel;
| | - Saar Dor
- Faculty of Medicine, Ben-Gurion University, Beer Sheva 8443944, Israel; (R.W.S.); (S.D.)
| | - Itamar Raz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem 91240, Israel
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12
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Nakajima H, Okada H, Yoshimura Y, Tanaka T, Hasegawa G, Mitsuhashi K, Kitagawa N, Okamura T, Hashimoto Y, Senmaru T, Ushigome E, Nakanishi N, Yamazaki M, Hamaguchi M, Fukui M. Younger patients and low c-peptide immunoreactivity index but not nutritional states affect fasting blood ketone levels in Japanese with type 1 diabetes after sodium-glucose cotransporter 2 inhibitor administration. Diabetes Obes Metab 2023; 25:3682-3689. [PMID: 37667649 DOI: 10.1111/dom.15262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 09/06/2023]
Abstract
AIM Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are available for individuals with type 1 diabetes, but appropriate use is recommended to prevent ketosis or ketoacidosis. This study aimed to evaluate the risk of ketosis in people with type 1 diabetes, focusing on the relationship between nutritional assessment, glycaemic status, c-peptide immunoreactivity (CPR) index and body composition. MATERIALS AND METHODS In total, 46 Japanese patients with type 1 diabetes were included, and dietary assessment from food photographs and ketone levels were evaluated before and after taking SGLT2is. The effect of diet on morning ketone levels was also investigated. RESULTS All patients had an increase in mean ketone concentrations after taking SGLT2is (before 0.12 ± 0.06 mmol/L, after 0.23 ± 0.16 mmol/L). A significant negative correlation was found between average morning ketone levels and age (r = -0.514, p < .001) and the CPR index (r = -0.523, p = .038) after taking SGLT2is. Using a mixed-effects model based on the results before starting the inhibitors, it was noted that both patient-to-patient and age, or patient-to-patient and capacity of insulin secretion, influenced the ketone levels. Multiple regression analysis showed that factors associated with the risk of increasing ketone levels after taking SGLT2is were younger age (β = -0.504, p = .003) and a low ratio of basal to bolus insulin (β = -0.420, p = .005). CONCLUSIONS When administering SGLT2is to patients with a low CPR index or younger patients with type 1 diabetes, adequate instructions to prevent ketosis should be given.
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Affiliation(s)
- Hanako Nakajima
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Hiroshi Okada
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Yuta Yoshimura
- Department of Endocrinology, Metabolism, and Diabetes, Saiseikai Suita Hospital, Osaka, Japan
| | - Toru Tanaka
- Department of Diabetes and Endocrinology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Goji Hasegawa
- Division of Metabolism and Rheumatology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Kazuteru Mitsuhashi
- Department of Diabetes Internal Medicine, Fukuchiyama City Hospital, Kyoto, Japan
| | | | - Takuro Okamura
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Yoshitaka Hashimoto
- Department of Diabetes and Endocrinology, Matsushita Memorial Hospital, Moriguchi, Japan
| | - Takafumi Senmaru
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Emi Ushigome
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Naoko Nakanishi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Masahiro Yamazaki
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Masahide Hamaguchi
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Michiaki Fukui
- Department of Endocrinology and Metabolism, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
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13
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Azizogli AR, Vitti MR, Mishra R, Osorno L, Heffernan C, Kumar VA. Comparison of SGLT1, SGLT2, and Dual Inhibitor biological activity in treating Type 2 Diabetes Mellitus. ADVANCED THERAPEUTICS 2023; 6:2300143. [PMID: 38223846 PMCID: PMC10783160 DOI: 10.1002/adtp.202300143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Indexed: 01/16/2024]
Abstract
Diabetes Mellitus Type 2 (T2D) is an emerging health burden in the USand worldwide, impacting approximately 15% of Americans. Current front-line therapeutics for T2D patients include sulfonylureas that act to reduce A1C and/or fasting blood glucose levels, or Metformin that antagonizes the action of glucagon to reduce hepatic glucose production. Next generation glucomodulatory therapeutics target members of the high-affinity glucose transporter Sodium-Glucose-Linked-Transporter (SGLT) family. SGLT1 is primarily expressed in intestinal epithelium, whose inhibition reduces dietary glucose uptake, whilst SGLT2 is highly expressed in kidney - regulating glucose reabsorption. A number of SGLT2 inhibitors are FDA approved whilst SGLT1 and dual SGLT1 & 2 inhibitor are currently in clinical trials. Here, we discuss and compare SGLT2, SGLT1, and dual inhibitors' biochemical mechanism and physiological effects.
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Affiliation(s)
- Abdul-Rahman Azizogli
- Department of Biological Sciences, New Jersey Institute of Technology, Newark, NJ, 07102
| | - Michael R Vitti
- University of Virginia School of Medicine, Charlottesville, VA, 22903
| | - Richa Mishra
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, 07102
| | - Laura Osorno
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, 07102
| | - Corey Heffernan
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, 07102
| | - Vivek A Kumar
- Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, NJ, 07102
- Department of Biological Sciences, New Jersey Institute of Technology, Newark, NJ, 07102
- Department of Chemical and Materials Engineering, New Jersey Institute of Technology, Newark, NJ, 07102
- Department of Endodontics, Rutgers School of Dental Medicine, Newark, NJ, 07103
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14
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Petersen C, Gyabaah F, Sotelo J, Yohanna S, Deoker A. A Case of Prolonged Recovery for Post-percutaneous Coronary Intervention (PCI) Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor-Induced Euglycemic Diabetic Ketoacidosis in a 28-Year-Old. Cureus 2023; 15:e45180. [PMID: 37842482 PMCID: PMC10575758 DOI: 10.7759/cureus.45180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/17/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (DKA) is a rare, but clinically important, presentation that can lead to significant morbidity and mortality in patients with diabetes mellitus. It has been associated with multiple etiologies, including sodium-glucose cotransport-2 (SGLT2) inhibitor use. This case report details the presentation of a 28-year-old male patient who was recently diagnosed with non-ST elevated myocardial infarction (NSTEMI) status post-percutaneous coronary intervention (PCI) to left anterior descending (LAD) and type 2 diabetes mellitus (T2DM) and discharged on a new medical regiment that included an SGLT2 inhibitor. The patient presented five days later with dyspnea, nausea, and vomiting. On initial evaluation, he had tachycardia and hypertension. Lab work revealed hyperkalemia, metabolic anion gap acidosis, and the presence of ketones and glucose in the urine, which led to the diagnosis of euglycemic DKA. The patient was started on intravenous (IV) insulin, bicarbonate, and D5 ½ normal saline (NS) and required five days of continuous treatment for the anion gap to close. Considering studies have shown that SGLT2 inhibitors are associated with euglycemic DKA, it is proposed that the use of an SGLT2 inhibitor in this newly diagnosed, post-PCI patient led to the development of euglycemic DKA. DKA most commonly resolves within 24 hours of treatment; however, our patient did not recover until after 120 hours of treatment. Recent studies have suggested that SGLT2-inhibitor euglycemic DKA may be associated with longer recovery time; however, there is still a need to further research the consistency of these findings and quantify the estimated duration of treatment across populations. There is also a need for investigation into how co-morbid factors, such as a recent NSTEMI and PCI, may affect recovery times or predispose patients who are taking SGLT2-inhibitors to develop euglycemic DKA as SGLT2 inhibitors are being more widely prescribed. This case report highlights the importance of creating more detailed and evidence-based guidelines for prescribing SGLT2 inhibitors for patients with diabetes and encourages more research into the expected duration of treatment for patients with SGLT2-induced euglycemic DKA and factors that may affect it.
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Affiliation(s)
- Cyrena Petersen
- Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, USA
| | - Frederick Gyabaah
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Jose Sotelo
- Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, USA
| | - Sandeesh Yohanna
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
| | - Abhizith Deoker
- Internal Medicine, Texas Tech University Health Sciences Center, El Paso, USA
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15
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Juneja D, Nasa P, Jain R, Singh O. Sodium-glucose Cotransporter-2 Inhibitors induced euglycemic diabetic ketoacidosis: A meta summary of case reports. World J Diabetes 2023; 14:1314-1322. [PMID: 37664476 PMCID: PMC10473945 DOI: 10.4239/wjd.v14.i8.1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/20/2023] [Accepted: 06/19/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are commonly prescribed to manage patients with diabetes mellitus. These agents may rarely lead to the development of euglycemic diabetic ketoacidosis (EDKA), which may complicate the disease course of these patients. AIM To analyze the demographic profile, predisposing factors, symptomology, clinical interventions and outcomes of patients presenting with EDKA secondary to SGLT2i use by reviewing the published case reports and series. METHODS We performed a systematic search of PubMed, Science Direct, Google Scholar and Reference Citation Analysis databases using the terms "canagliflozin" OR "empagliflozin" OR "dapagliflozin" OR "SGLT2 inhibitors" OR "Sodium-glucose cotransporter-2" AND "euglycemia" OR "euglycemic diabetic ketoacidosis" OR "metabolic acidosis". The inclusion criteria were: (1) Case reports or case series with individual patient details; and (2) Reported EDKA secondary to SGLT2i. Furthermore, the data were filtered from the literature published in the English language and on adults (> 18 years). We excluded: (1) Conference abstracts; and (2) Case reports or series which did not have individual biochemical data. All the case reports and case series were evaluated. The data extracted included patient demographics, clinical symptomatology, clinical interventions, intensive care unit course, need for organ support and outcomes. RESULTS Overall, 108 case reports and 17 cases series with 169 unique patients that met all the inclusion criteria were included. The majority of patients were females (54.4%, n = 92), and the commonly reported symptoms were gastrointestinal (nausea/vomiting 65.1%, abdominal pain 37.3%) and respiratory (breathlessness 30.8%). One hundred and forty-nine (88.2%) patients had underlying type II diabetes, and the most commonly involved SGLT-2 inhibitor reported was empagliflozin (46.8%). A triggering factor was reported in most patients (78.7%), the commonest being acute severe infection (37.9%), which included patients with sepsis, coronavirus disease 2019, other viral illnesses, and acute pancreatitis. 61.5% were reported to require intensive unit care, but only a minority of patients required organ support in the form of invasive mechanical ventilation (13%), vasopressors (6.5%) or renal replacement therapy (5.9%). The overall mortality rate was only 2.4%. CONCLUSION Patients on SGLT2i may rarely develop EDKA, especially in the presence of certain predisposing factors, including severe acute infections and following major surgery. The signs and symptoms of EDKA may be similar to that of DKA but with normal blood sugar levels, which may make the diagnosis challenging. Outcomes of EDKA are good if recognized early and corrective actions are taken. Hence, physicians managing such patients must be aware of this potential complication and must educate their patients accordingly to ensure early diagnosis and management.
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Affiliation(s)
- Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
- Department of Internal Medicine, College of Medicine and Health Sciences, Al Ain 15551, Abu Dhabi, United Arab Emirates
| | - Ravi Jain
- Department of Critical Care Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur 302022, Rajasthan, India
| | - Omender Singh
- Institute of Critical Care Medicine, Max Super Speciality Hospital, Saket, New Delhi 110017, India
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16
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Scheen AJ. Use of SGLT2 inhibitors after bariatric/metabolic surgery: Risk/benefit balance. DIABETES & METABOLISM 2023; 49:101453. [PMID: 37245675 DOI: 10.1016/j.diabet.2023.101453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/30/2023]
Abstract
Bariatric/metabolic surgery and sodium-glucose cotransporter 2 inhibitors (SGLT2is) are becoming increasingly popular for the management of overweight/obese patients with type 2 diabetes mellitus (T2DM). Consequently, the chance that a patient undergoing bariatric/metabolic surgery is also treated with an SGLT2i would be rather common in clinical practice. Both risks and benefits have been reported. On the one hand, several cases of euglycemic diabetic ketoacidosis have been reported within the few days/weeks after bariatric/metabolic surgery. The causes are diverse but a drastic reduction in caloric (carbohydrate) intake most probably plays a crucial role. Thus, SGLT2is should be stopped a few days (and even more if a pre-operative restricted diet is prescribed to reduce liver volume) before the intervention and reintroduced only when the caloric (carbohydrate) intake is sufficient. On the other hand, SGLT2is may exert a favorable effect to reduce the risk of postprandial hypoglycemia, a complication reported among patients who have been treated with bariatric/metabolic surgery. An increased hepatic glucose production and a reduced production of interleukin-1β have been proposed as possible underlying mechanisms for this protective effect. Finally, whether SGLT2is could prolong diabetes remission following surgery and improve the prognosis of patients with T2DM who benefit from bariatric/metabolic surgery remains to be investigated.
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Affiliation(s)
- André J Scheen
- Division of Clinical Pharmacology, Centre for Interdisciplinary Research on Medicines (CIRM), Liège University, Liège, Belgium; Division of Diabetes, Nutrition and Metabolic Disorders, CHU Liège, Liège, Belgium.
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17
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Wu G, Wu S, Tang J, Wu H. Delayed euDKA Associated With Dapagliflozin After Pancreatitis. Clin Ther 2023; 45:e167-e170. [PMID: 37248092 DOI: 10.1016/j.clinthera.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/26/2023] [Accepted: 05/06/2023] [Indexed: 05/31/2023]
Abstract
Euglycemic diabetic ketoacidosis (euDKA) is a rare but life-threatening adverse effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors. We present a case of delayed euDKA seven days after cure of acute pancreatitis and discharge from the hospital of a 51-year-old man with type 2 diabetes mellitus (T2DM) managed with a combination of antidiabetic medications, including the SGLT2 inhibitor dapagliflozin. Prior acute pancreatitis was postulated to be a contributing factor to the development of SGLT2 inhibitor-associated euDKA in this patient discharged from the hospital. The patient was managed accordingly and improved clinically while his oral hypoglycemic agents were stopped. The risk of euDKA from SGLT2 inhibitor therapy may be increased by some stress factors (eg, infection, surgery, acute illness, low-carbohydrate diet, excessive alcohol intake). As these SGLT2 inhibitors become a popular therapeutic strategy for the management of hyperglycemia in T2DM, clinicians should be aware that acute illnesses such as pancreatitis in patients with T2DM can be potential predisposing factors for the development of SGLT2 inhibitor-associated euDKA.
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Affiliation(s)
- Gao Wu
- Department of Pharmacy, First Affiliated Hospital of Naval Military Medical University, Shanghai, China
| | - Shuxie Wu
- Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, China
| | - Jin Tang
- Department of Intensive Care Unit, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hanbin Wu
- Clinical Pharmacy, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China.
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18
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Dutta S, Shah RB, Singhal S, Dutta SB, Bansal S, Sinha S, Haque M. Metformin: A Review of Potential Mechanism and Therapeutic Utility Beyond Diabetes. Drug Des Devel Ther 2023; 17:1907-1932. [PMID: 37397787 PMCID: PMC10312383 DOI: 10.2147/dddt.s409373] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/10/2023] [Indexed: 07/04/2023] Open
Abstract
Metformin has been designated as one of the most crucial first-line therapeutic agents in the management of type 2 diabetes mellitus. Primarily being an antihyperglycemic agent, metformin also has a plethora of pleiotropic effects on various systems and processes. It acts majorly by activating AMPK (Adenosine Monophosphate-Activated Protein Kinase) in the cells and reducing glucose output from the liver. It also decreases advanced glycation end products and reactive oxygen species production in the endothelium apart from regulating the glucose and lipid metabolism in the cardiomyocytes, hence minimizing the cardiovascular risks. Its anticancer, antiproliferative and apoptosis-inducing effects on malignant cells might prove instrumental in the malignancy of organs like the breast, kidney, brain, ovary, lung, and endometrium. Preclinical studies have also shown some evidence of metformin's neuroprotective role in Parkinson's disease, Alzheimer's disease, multiple sclerosis and Huntington's disease. Metformin exerts its pleiotropic effects through varied pathways of intracellular signalling and exact mechanism in the majority of them remains yet to be clearly defined. This article has extensively reviewed the therapeutic benefits of metformin and the details of its mechanism for a molecule of boon in various conditions like diabetes, prediabetes, obesity, polycystic ovarian disease, metabolic derangement in HIV, various cancers and aging.
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Affiliation(s)
- Siddhartha Dutta
- Department of Pharmacology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
| | - Rima B Shah
- Department of Pharmacology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
| | - Shubha Singhal
- Department of Pharmacology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
| | - Sudeshna Banerjee Dutta
- Department of Medical Surgical Nursing, Shri Anand Institute of Nursing, Rajkot, Gujarat, 360005, India
| | - Sumit Bansal
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
| | - Susmita Sinha
- Department of Physiology, Khulna City Medical College and Hospital, Khulna, Bangladesh
| | - Mainul Haque
- Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, 57000, Malaysia
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19
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Armstrong MT, Murray-Ramcharan M, Flory JH, Jarnagin WR, Wei AC. Sodium-glucose cotransporter 2 inhibitor-induced postoperative euglycaemic diabetic ketoacidosis after pancreatectomy. Br J Surg 2023; 110:545-547. [PMID: 36869846 PMCID: PMC10577519 DOI: 10.1093/bjs/znad044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 03/05/2023]
Affiliation(s)
- Misha T Armstrong
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - James H Flory
- Endocrinology Service, Department of Subspecialty Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - William R Jarnagin
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alice C Wei
- Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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20
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Muacevic A, Adler JR, Dhillon GS, Shah P. Empagliflozin-Associated Euglycemic Diabetic Ketoacidosis in a Patient With Type 2 Diabetes Mellitus. Cureus 2023; 15:e33892. [PMID: 36819400 PMCID: PMC9934848 DOI: 10.7759/cureus.33892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
Euglycemic diabetic ketoacidosis (euDKA) is an uncommon condition, which is characterized by an elevated anion gap metabolic acidosis with ketonemia/ketonuria, in the presence of normal blood glucose levels. Common risk factors for the development of this condition include pregnancy, prolonged fasting, acute pancreatitis, and bariatric surgery. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been identified as a rare cause of euDKA. A recent literature review on PubMed found only 86 case reports of euDKA secondary to SGLT inhibitors published in the medical literature up to December 2022. Here, we present the case of a 43-year-old man who was taking empagliflozin, an SGLT-2 inhibitor. The patient was found to have euDKA, which was likely an adverse effect of his medication.
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21
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Brust-Sisti L, Rudawsky N, Gonzalez J, Brunetti L. The Role of Sodium-Glucose Cotransporter-2 Inhibition in Heart Failure with Preserved Ejection Fraction. PHARMACY 2022; 10:pharmacy10060166. [PMID: 36548322 PMCID: PMC9788031 DOI: 10.3390/pharmacy10060166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 12/03/2022] Open
Abstract
Sodium-glucose cotransporter-2 (SGLT2) inhibitors are a novel class of antidiabetic mediations found to also reduce cardiovascular morbidity and mortality and hospitalization for heart failure. Positive results from the EMPEROR-Preserved (empagliflozin) and PRESERVED-HF (dapagliflozin) studies led to recommendations for SGLT2 inhibitors in HFpEF within major international heart failure guidelines. However, studies of ipragliflozin and luseogliflozin, agents approved outside the United States (U.S.), reported different outcomes relative to pivotal trials and failed to realize benefits in the HFpEF population. Varying definitions of HFpEF and outcomes studied complicate the interpretation of study results. SGLT2 inhibitors may cause common adverse events (genital mycotic infections, volume depletion) in addition to rare but severe sequela, including euglycemic diabetic ketoacidosis, Fournier's gangrene, and lower limb amputation. While evidence of CV benefits grows, SGLT2 inhibitor prescribing has lagged, particularly among patients without diabetes. In the U.S., high cost and administrative hurdles may contribute to decreased patient and clinician uptake of this drug class. Future trial results and clinical experience with SGLT2 inhibitors may lead to expanded use and greater uptake among patients with heart failure.
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Affiliation(s)
- Lindsay Brust-Sisti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Nicole Rudawsky
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Jimmy Gonzalez
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
| | - Luigi Brunetti
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Piscataway, NJ 08854, USA
- Correspondence: ; Tel.: +1-848-445-6815
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22
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Mahfooz RS, Khan MK, Al Hennawi H, Khedr A. SGLT-2 Inhibitor-Associated Euglycemic Diabetic Ketoacidosis: A Case Report and a Literature Review. Cureus 2022; 14:e26267. [PMID: 35911365 PMCID: PMC9313009 DOI: 10.7759/cureus.26267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 12/04/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is considered a medical emergency, most commonly associated with type 1 diabetes mellitus, and is relatively rare in type 2 diabetes mellitus (T2DM). We discuss a case of a 45-year-old woman with T2DM who presented to the emergency room with worsening lethargy and weakness. Before her presentation, her physician had recently added empagliflozin, a sodium-glucose cotransporter-2 (SGLT-2) inhibitor, to her anti-diabetic drug regimen along with glimepiride and a combination drug of vildagliptin and metformin. Based on the clinical examination and lab findings, DKA was suspected, but her glucose level was below the cutoff value for DKA diagnosis. However, her lab results showed significant metabolic acidosis and ketonemia with no clinical or laboratory features of sepsis. Therefore, the diagnosis of euglycemic diabetic ketoacidosis (eu-DKA) was made. She was successfully treated according to the DKA protocol and discharged in good condition. In this report, our aim is to discuss the relationship between SGLT-2 inhibitors with eu-DKA. Given the absence of significant hyperglycemia, recognition of this entity by clinicians may be delayed. Serum ketones should be obtained in diabetic patients with symptoms of nausea, vomiting, or malaise while taking SGLT-2 inhibitors, and SGLT-2 inhibitors should be discontinued if ketoacidosis is confirmed.
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23
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Anton IC, Mititelu-Tartau L, Popa EG, Poroch M, Poroch V, Pintilei DR, Botnariu GE. Clinical Parameters Affecting the Therapeutic Efficacy of SGLT-2—Comparative Effectiveness and Safety of Dapagliflozin and Empagliflozin in Patients with Type 2 Diabetes. Healthcare (Basel) 2022; 10:healthcare10071153. [PMID: 35885680 PMCID: PMC9316348 DOI: 10.3390/healthcare10071153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/08/2022] [Accepted: 06/16/2022] [Indexed: 11/30/2022] Open
Abstract
(1) Background. We aimed to assess long-term efficacy and safety in inadequately controlled type 2 diabetes (T2DM) of two SGLT-2 inhibitors: empagliflozin (Empa) and dapagliflozin (Dapa), combined with metformin, other oral antidiabetics or insulin, according to the protocols in Romania. (2) Methods. The data of 100 patients treated for T2DM with associated dyslipidemia and/or cardiovascular diseases at the University Hospital and Consultmed Medical Center in Iasi were retrospectively reviewed (2017–2021). In total, 48 patients had received dapagliflozin (10 mg with oral antidiabetics or insulin) and 52 patients received empagliflozin (10 mg /25 mg with oral antidiabetics). (3) Results. In both groups, the lowering of BMI was significant: Dapa group (32.04 ± 4.49 vs. 31.40 ± 4.18 kg/m2; p = 0.006), and Empa group (34.16 ± 5.08 vs. 33.17 ± 4.99 kg/m2; p = 0.002). Blood sugar average levels decreased significantly (170 vs. 136 mg/dL; p = 0.001 for Dapa; 163 vs. 140 mg/dL; p = 0.002 for Empa) and also average levels of HbA1c (7.90% vs. 7.51%; p = 0,01 for Dapa; 7.72% vs. 7.35%; p = 0.004 for Empa). (4) Conclusions. Better results in all variables were observed in younger male patients with a shorter duration of diabetes and threshold BMI levels of 34.1, treated with SGLT2, and more significantly with Empa.
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Affiliation(s)
- Irina Claudia Anton
- Department of Pharmacology, Clinical Pharmacology and Algesiology, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, Universitatii St. 16, 700115 Iasi, Romania;
| | - Liliana Mititelu-Tartau
- Department of Pharmacology, Clinical Pharmacology and Algesiology, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, Universitatii St. 16, 700115 Iasi, Romania;
- Correspondence: (L.M.-T.); (E.G.P.)
| | - Eliza Gratiela Popa
- Department of Pharmaceutical Technology, Faculty of Pharmacy, ‘Grigore T. Popa’ University of Medicine and Pharmacy, Universitatii St. 16, 700115 Iasi, Romania
- Correspondence: (L.M.-T.); (E.G.P.)
| | - Mihaela Poroch
- Department of Family Medicine, Preventive Medicine and Interdisciplinarity, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, Universitatii St. 16, 700115 Iasi, Romania;
| | - Vladimir Poroch
- 2nd Department of Internal Medicine, Faculty of Medicine, ‘Grigore T. Popa’ University of Medicine and Pharmacy, Universitatii St. 16, 700115 Iasi, Romania;
| | - Delia Reurean Pintilei
- Department of Diabetes, Nutrition and Metabolic Disease, Consultmed Medical Center, Pacurari St. 70, 700544 Iasi, Romania;
| | - Gina Eosefina Botnariu
- Department of Diabetes, Nutrition and Metabolic Disease, ‘Grigore T. Popa’ University of Medicine and Pharmacy, Universitatii St. 16, 700115 Iasi, Romania;
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